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<head>
<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
<title>Health-Watcher - Insert Special Complaint</title>
</head>

<body>
<script language="javascript">
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<h1>Special Complaint</h1>

<form method="POST" action="HWServlet" name="formQueixaDiversa">
  <input type="hidden" name="operation" values="InsertSpecialComplaint">
  <p>Complaint Description: </p>
  <p><textarea rows="6" name="descricaoQueixa" cols="63"></textarea></p>
  <p>Observations:</p>
  <p><textarea rows="2" name="observacaoQueixa" cols="63"></textarea><br>
  </p>
  <h3>Complainer Data</h3>
  <p>Complainer name: <input type="text" name="nomeSolicitante" size="41"></p>
  <p>Address: <input type="text" name="ruaSolicitante" size="36">&nbsp;&nbsp;&nbsp;
  Complement: <input type="text" name="compSolicitante" size="46">&nbsp;</p>
  <p>Province: <input type="text" name="bairroSolicitante" size="20"> </p>
  <p>City: <input type="text" name="cidadeSolicitante" size="20">&nbsp;&nbsp;&nbsp; State:
  &nbsp;&nbsp;&nbsp; <input type="text" name="ufSolicitante" size="3">
  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ZIP Code: <input type="text" name="cepSolicitante"
  size="17"></p>
  <p>Phone number:&nbsp;&nbsp;&nbsp; <input type="text" name="telefoneSolicitante" size="18"></p>
  <p>E-mail: <input type="text" name="emailSolicitante" size="39"></p>
  <h3>Event information</h3>
  <p>Age: <input type="text" name="idade" size="9">&nbsp;&nbsp;&nbsp; School level: <input
  type="text" name="instrucao" size="14"> &nbsp;&nbsp;&nbsp; Ocuppation:&nbsp;&nbsp;&nbsp; <input
  type="text" name="ocupacao" size="16"></p>
  <p>Event's address: <input type="text" name="ruaOcorrencia" size="36">&nbsp;&nbsp;&nbsp;Complement:
  <input type="text" name="compOcorrencia" size="40">&nbsp;&nbsp;&nbsp; </p>
  <p>Province: <input type="text" name="bairroOcorrencia" size="20"> </p>
  <p>City: <input type="text" name="cidadeOcorrencia" size="20">&nbsp;&nbsp;&nbsp; State:
  &nbsp;&nbsp;&nbsp; <input type="text" name="ufOcorrencia" size="3">
  &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ZIP code: <input type="text" name="cepOcorrencia"
  size="17"></p>
  <p>Phone number&nbsp;&nbsp;&nbsp; <input type="text" name="telefoneOcorrencia" size="18"></p>
  <div align="center"><center><p><input type="button" value="Insert" name="bt1"
  onClick="javascript:submeterDados();"> <input type="reset" value="Clear" name="bt2"> </p>
  </center></div>
</form>

<p><center><a href="index.html">Main menu</a><p><small>Health-Watcher - 2004</small></center>
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